Angina Pectoris: Prinzmetal's Variant

Cardiology (12%) Core Clinical Conditions

1B: Able to identify the condition as a possible diagnosis: may not have the knowledge or resources to confirm the diagnosis or to manage the condition safely, but can take measures to avoid immediate deterioration and refer appropriately

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Definition Aetiology Pathophysiology Risk factor Sign and Symptoms Investigations Management

Prinzmetal's variant angina, also known as variant angina or coronary artery spasm, is a type of angina that occurs when the coronary artery narrows or constricts, reducing blood flow to the heart muscle. This type of angina is different from the more common type, known as stable angina, which is caused by a buildup of plaque in the coronary artery.

Prinzmetal's variant angina typically occurs at rest, often during the early morning hours, and is triggered by factors such as stress, exposure to cold, or smoking. The chest pain or discomfort associated with Prinzmetal's variant angina can be severe and is often described as a tightness or squeezing sensation. Other symptoms can include shortness of breath, sweating, and a rapid or irregular heartbeat.

The exact cause of Prinzmetal's variant angina (PVA) is not well understood, but it is believed to be related to the abnormal constriction or spasm of the coronary artery. This can occur due to a variety of factors, including:

• Abnormalities in the smooth muscle cells that line the coronary artery: These abnormalities can cause the artery to constrict more easily, reducing blood flow to the heart muscle.

• High levels of catecholamines: Catecholamines are hormones that are released in response to stress and can cause the coronary artery to constrict.

• Low levels of oxygen in the blood: This can occur due to respiratory or cardiovascular conditions and can cause the coronary artery to constrict.

• Exposure to cold: Cold temperatures can cause the coronary artery to constrict, reducing blood flow to the heart muscle.

• Smoking or other forms of tobacco use: Nicotine in tobacco can cause the coronary artery to constrict, reducing blood flow to the heart muscle.

• Certain medications: Certain medications such as ergot alkaloids and cocaine can cause coronary artery spasm.

Prinzmetal's variant angina (PVA) is a type of angina that is caused by the abnormal constriction or spasm of a coronary artery, which reduces blood flow to the heart muscle. The pathology of PVA is related to the spasm of the coronary artery, which can cause the following changes in the heart:

• Ischemia: When the coronary artery constricts, it reduces the amount of oxygen and nutrients that reach the heart muscle. This can cause the heart muscle to become ischemic, which means that it doesn't receive enough blood and oxygen to function properly.

• Myocardial infarction: If the coronary artery spasm is severe and prolonged, it can cause a myocardial infarction (heart attack) in the area of the heart muscle that is supplied by the constricted artery.

• Myocardial necrosis: When the heart muscle doesn't receive enough oxygen, the cells in the affected area will die and will be replaced by scar tissue.

• Electrical instability: PVA can cause an electrical instability in the heart, leading to arrhythmias. These can be life-threatening if not treated promptly.

• Increased demand for oxygen: PVA can also cause an increased demand for oxygen in the heart, leading to heart failure if the spasm is prolonged.

There are several risk factors that can increase a person's likelihood of developing Prinzmetal's variant angina (PVA), including:

• High blood pressure: hypertension increases the workload on the heart and can damage the blood vessels over time.

• High cholesterol: high levels of LDL cholesterol in the blood can contribute to the development of PVA.

• Smoking: smoking damages the blood vessels and increases the risk of blood clots.

• Family history: a family history of PVA increases the risk of developing the condition.

• Age: PVA is more common in younger people and in women.

• Exposure to cold: Cold temperatures can cause the coronary artery to constrict, reducing blood flow to the heart muscle.

• Certain medications: Certain medications such as ergot alkaloids and cocaine can cause coronary artery spasm.

• Certain medical conditions: such as hyperthyroidism, pheochromocytoma, and sarcoidosis can increase the risk of PVA.

The signs and symptoms of Prinzmetal's variant angina (PVA) can vary, but typically include chest pain or discomfort, which is often described as a tightness or squeezing sensation. Other symptoms of PVA can include:

• Chest pain or discomfort that occurs at rest, often in the early morning hours.

• Chest pain or discomfort that is triggered by factors such as stress, exposure to cold, or smoking.

• Shortness of breath: this can be a sign that the heart is not pumping enough blood.

• Sweating: a cold sweat can be a symptom of PVA.

• Rapid or irregular heartbeat: this can be caused by the electrical instability in the heart caused by the PVA.

• Nausea and vomiting: some people may feel sick to their stomach or even vomit.

It's worth noting that PVA symptoms can be similar to those of stable angina. However, PVA typically occurs at rest and is triggered by specific factors such as stress, exposure to cold, or smoking, rather than by physical activity or emotional stress.

There are several investigations that can be used to diagnose Prinzmetal's variant angina (PVA). Some common tests include:

• Electrocardiogram (ECG): This test records the electrical activity of the heart and can show if an area of the heart muscle has been damaged or is not getting enough blood flow. ECG can help identify the characteristic changes associated with PVA, such as ST-segment elevation and T-wave inversion during the chest pain episode.

• Coronary angiography: This is an invasive test that uses X-ray and a special dye to create pictures of the coronary artery. It can show if there is a blockage in one or more of the coronary arteries, and also identify coronary artery spasms.

• Exercise tolerance test (ETT): This test is used to evaluate how the heart responds to exercise, and can help identify PVA, which often occurs at rest.

• Ambulatory ECG: This test records the electrical activity of the heart over a period of time, and can help identify episodes of PVA that occur during the day or night.

The treatment of Prinzmetal's variant angina (PVA) will vary depending on the severity of the condition and the individual's overall health, but some common treatments include:

• Medications: Nitrates, calcium channel blockers, and beta-blockers are commonly used to help relax and widen the coronary artery, and to prevent spasm.

• Coronary angioplasty and stenting: This procedure involves the insertion of a balloon catheter into the blocked coronary artery, the balloon is then inflated to open the blocked artery and a stent, a small metal mesh tube, is inserted to keep the artery open.

• Coronary artery bypass surgery: This procedure involves the use of a healthy blood vessel from another part of the body to bypass the blocked coronary artery, improving blood flow to the heart muscle.

• Lifestyle changes: such as quitting smoking, avoiding exposure to cold temperatures, and managing stress can help to reduce the risk of PVA.

• Long-term treatment: To prevent recurrent episodes of PVA, long-term treatment with medications such as diltiazem, verapamil, nifedipine, or nicardipine is recommended.

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